Who Pays the Tab For Unfunded Care?

If the United States were to re-instate the draft and emergency physicians were required by law to serve their country, an EP could reasonably expect that the government would pay for that service. Undoubtedly it would be a fraction of what EPs receive under a civilian contract, but it wouldn’t be nothing. Being conscripted for service for no remuneration? That’s called slavery.

Yet that is exactly what has happened for the last 29 years under unreimbursed EMTALA. An emergency physician who refuses to care for a patient because of their refusal to pay can face up to a $50,000 fine per violation. Of course, the physician can always pursue the patient for payment. But if they cannot or will not pay, there is very little further recourse for the physician. And the government that mandated the care is deemed exempt from any liability for the bill. This is simply un-American.

For years, ACEP has appealed to Congress for some type of reimbursement to emergency physicians for such mandated care. But these cries have always seemed to fall on deaf ears. In the grand scheme of things, emergency physicians are considered a small group of well compensated citizens who can easily afford such an imposition on their time and wallets. But there are bigger issues at stake with this unfunded mandate, beyond its impact on our bottom line.

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The first issue is simple fairness. Is every grocery store required to give food free of charge to customers who claim that they are not able to pay the bill? No. Instead we created the food stamp program to help those without means obtain food. But what about those who either don’t qualify for food stamps or simply choose not to go to the trouble to sign up for the program. Does the burden of feeding these folks fall back on the grocery store or restaurant? The answer is no. Grocers can and do show charity to the less fortunate. But they are not selected by their business code for specific responsibility to provide life-sustaining food to those who cannot or will not pay for it.

Through charity programs the government has taken on the burden of making sure that the least fortunate of its citizens are fed. But the burden for such is borne proportionally amongst all its citizens. And those who fail to take advantage of this system of charity are simply out of luck. Not so with emergency medical care. Instead, the cost of unreimbursed EMTALA care is shifted from those who cannot pay to those who can, skewing costs for everyone. The problem here again is inequality.

Hospitals in areas with a high indigent population must shift more of the cost of unreimbursed care than those in areas of low unreimbursed care. It’s like increasing the taxes in poor areas and lowering taxes in affluent areas. Furthermore, since the bills are different with each patient, some will receive a higher proportion of shift than others. It’s like raising taxes on the sickest patients just because they have the ability to pay.

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Under the Affordable Care Act, Medicaid was expanded to cover everyone who did not have the means to purchase mandated insurance. However, the Act is toothless in its ability to enforce sign-ups to the program. Uninsured poor still have little motivation to sign up for Medicaid when they find that it’s simply easier to go to the ED. Those that have signed up for Medicaid have often found that they cannot get into a provider’s office due to a crowded schedule. Far from seeing drops in emergency department visits from the newly insured poor, many states have seen dramatic increases. The ED is still the option of convenience. So the only motivation for signing up becomes getting a payment for the provider. Shockingly, that is not a huge incentive for most of my patients.

But there is hope; there is a movement in congress to address this situation. Recent bills that offer to reform the Affordable Care Act have included provisions for a partial tax credit to emergency physicians who provide unreimbursed EMTALA mandated care. The important feature of this provision is that these are tax credits, not reductions to income such as those received for charitable giving. Why? Again it goes to treating everyone equally. If a wealthy tax payer who pays a higher proportion of this income gives to charity, his benefit from charitable donation is proportionally higher. Thus lower income or even taxpayers who already lower their taxable income through charity will feel a smaller effect from the reduction of income. Tax credits, on the other hand, affect all taxpayers equally. If I made $100k per year and provided $10,000 of unreimbursed, mandated care, I would receive the same $10,000 tax reduction as the EP who made $200k and provided $10,000 of unreimbursed care.

Of course, don’t plan on anyone receiving dollar for dollar tax credits for “charges” for unreimbursed care. First, that would lead to charge inflation in the hopes of tax credit inflation. But more importantly, the government never pays charges for anything, but pays a portion of the charge, probably the Medicaid rate. Opponents of such a system – even within our own specialty – will argue that it would be a windfall to the groups we work for and never be seen by the actual providers. And there is no doubt that it would add tax complexity and a higher burden of proof for physicians seeking disbursement from the government.

And yet it is an idea whose time may have finally come. I have circulated an online petition for emergency physicians to sign who support discussion of such tax credits for unreimbursed EMTALA mandated care. Over 600 EPs signed it in the first few hours after receiving the email. But our specialty has more than 30,000 members. Are you interested? Even the most pessimistic among you – those who think such a bill could never be passed in our divided congress – should appreciate that it is time to have a cogent discussion of who is actually bearing the cost of this EMTALA-mandated “right” to health care.

FOUNDER / EXECUTIVE EDITOR
Dr. Plaster has been an emergency physician for more than thirty years, working exclusively night shifts for the past twenty years in emergency departments across the country. During that period he joined the U.S. Navy and served two tours in Iraq. Dr. Plaster is the founder and executive editor of Emergency Physicians Monthly and the founder of Plaster Publishing.

“I was entranced by an essay in Emergency Physicians Monthly . . . If you want to know what professional craftsmanship looks like, this is it. ”

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